NANDA-Nursing Plan Area4 activity/rest

NANDA-Nursing Plan 00110 Toileting self-care dificit

NANDA-Nursing Plan 00110 Toileting self-care dificit

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 4 Activity/Rest
production, storage, consumption, or balance of energy resources
Category 5 Self-care
Ability to carry out activities to care for one’s body and bodily functions

Toileting self-care difficit 00110

Nursing Diagnosis;Toileting self-care difficit
Definition: Impaired ability to perform or complete toileting behaviors on one’s own behalf.

1.Toileting self-care dificit target

・ Decreased motivation (psychiatric disorders, dementia, etc.)
・Cognitive decline
・Do not know the procedure for excretion (putting on and taking off pants and underwear, how to use toilet paper)
・I don’t know where the toilet is
・Anxiety or resignation about excretion such as incontinence
・Psychiatric disorders (decreased motivation)
・paralysis
・Motor paralysis: difficult to excrete on one’s own
・Difficulty in standing, difficulty in sitting, narrow range of motion of upper extremities
・Takes time to move
・Sensory paralysis: no urge to defecate, no urge to urinate
・It is not the excretion environment that was in ADL
・There is no handrail
・The toilet seat is low (even if you can sit down, you can’t stand up)
・The way to the toilet at night is dark
・The toilet is cold
·fracture
・Compression fractures (posture imbalance, pain)
・Stoma
・Difficult to self-manage
(Inability to replace or excrete appropriately, difficult to dispose of excrement after disposal)
・Spatial neglect (limited visibility)
・Neuromuscular disease (weakness, involuntary movements, etc.)
・Musculoskeletal disorders: difficulty in sitting, difficulty in standing, difficulty in wheelchairs and portable transfers
・Pain: pain occurs when standing or sitting
・ Knee joint disease
・Cardiac dysfunction (pain, palpitation, chest pain, excretion, such as movement and exertion)
・Respiratory dysfunction (breathing becomes difficult due to excretion activities such as movement and effort, inhalation of oxygen)
・Exhaustive fatigue

2. aim setting

1) Goal setting by linkage (published in the second half of NOC)

*Linkage has the role of connecting NANDA (diagnosis) and NOC (results).
・Self-care: excretion, behavior, cleanliness
・Ostomy self-care
・walking
・Transportation: Wheelchair
・Body balance
・Cognition
・Pain level
The level of debilitating fatigue

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・Able to excrete on their own by selecting self-help tools and welfare tools that match their remaining functions.
Can describe and actually manage stoma management.
・In order to reduce motivation due to incontinence, it is possible to adopt measures according to the type of incontinence (use of pads, assistive devices, etc.).
・It is possible to prepare a living environment that makes use of the remaining functions.
・It is possible to incorporate lifestyle rehabilitation to maintain ADL.

*Nurse goals include:

・Prepare self-help tools suitable for ADLs and disabilities to maintain excretion self-care.
– Prepare an environment for lack of continence healthcare due to declining cognitive function.
・Support the acquisition of stoma management methods.
・Intervene according to the type of incontinence when the motivation is decreased due to incontinence.
・Listen to the complainants and their families, and try to alleviate their concerns.
・Give advice to the person and their family members and have them acquire knowledge and skills so that they can live with their remaining functions.
・Introduce life rehabilitation to maintain ADL.

3. nursing plan

1) Observation Plan 《OP》

(1) Physical factors

・age
・Cognitive function: MMSE score of 21 or less, Hasegawa score of 20 or less, dementia suspected
・Dietary intake, food content, water intake
・Medical history, current disease history, etc.:
 *Digestive system disease: cause of diarrhea
 * Urinary system diseases: cystitis, neurogenic bladder, etc.
 *Musculoskeletal diseases: disorders of range of motion and joints
 * Cerebrovascular diseases, intracerebral lesions: disorders of the central nervous system that controls excretion, disorders of the urge to defecate and urinate, paralysis, motor dysfunction
 *Pulmonary diseases such as pulmonary hypertension and COPD: respiratory distress, need for oxygen inhalation
 * Cardiac disease: chest symptoms due to exertion
 *Fracture: Includes compression fractures. Reduced range of motion and pain associated with movement
 * Consuming diseases: severe infections, anemia, dehydration, hypoproteinemia, etc.
 * Cancer: Various symptoms such as pain, neurological symptoms, and respiratory distress appear depending on the place of metastasis. There is also an impact on life.
・ADL, IADL: Regarding excretion, how far can you go on your own and are you willing to do it yourself?
・Actual excretion: which part is not made
・Urinary pattern, defecation pattern
・Caregiver’s ability to care, degree of intervention
・Vital signs (at rest and after exertion)
・Blood pressure, pulse pressure, left-right difference, pulse deficit
・Heart rate (bradycardia, tachycardia), pulse rate (bradycardia, tachycardia), difference between heartbeat and pulse
・SPO2
・pain:
・Degree of pain: face scale, pain scale, etc.
・Timing of pain appearance: pain at rest, pain on exertion
・Pain area
Types of pain; stabbing pain, sudden pain, pain that feels like pressure, etc.
・Presence or absence of painkillers
・Paralysis: site, range, complete paralysis, partial paralysis
・ Residual function in case of paralysis
・ Presence or absence of caregiver, caregiver’s ability to care
・Peripheral sensations (fingertips and toes)
・Image inspection
・XP, CT: pleural effusion, ascites, fracture, brain injury site, etc.
・Muscular strength: MMT, transfer ability (wheelchair, portable toilet)
・Joint range of motion
・Subjective symptoms:
・Dyspnea, chest pain, palpitations
·dizzy
・Venous blood data
・Anemia (RBC, Hb, HT)
・As infection (procalcitonin, CRP, WBC, granulocytes/lymphocytes) inflammation progresses, the coagulation system also
・Hypoproteinemia (Alb, TP)
Cardiogenic shock symptoms
・Low blood pressure, loss of consciousness, decreased urine output, etc.
·electro-cardiogram
· Arrhythmia
・ Oral medicine (Try following the 6Rs. Check what you are taking and what risks you are taking.)

(2) Environmental factors

・The environment of the toilet: The place is far away, it is outside and it is cold, so you don’t want to go, etc.
・Transportation to the toilet: Handrails are not in the proper position
・Presence or absence of a care manager, contents of the plan

2) Action plan 《TP》

・Provide care that considers safety, comfort, and independence. (utilize remaining functions)
・Improve the excretion environment
・Make a mark with fluorescent tape so that the location of the toilet can be seen.
・Take measures such as footlights so that your feet are bright even at night.
· Install a portable toilet.
・Prepare a pulse oximeter and blood pressure monitor just in case to deal with sudden chest discomfort and respiratory distress when assisting with excretion.
・Understand excretion patterns. Guidance according to patterns.
・Choose clothes that are easy to excrete (use rubber pants and rehabilitation pants)
・Help with defecation
・Help transfer wheelchairs. Assist only in areas where the patient is unable to do so.
・If the urine pad is contaminated, replace it. Use it repeatedly to avoid skin troubles.
· Assist while telling how to use the handrail, such as how to stand up. Watch over until you can smoothly do it yourself.
・ If it is difficult to stand up, install handrails, auxiliary toilet seats (there are goods that can adjust the height of the toilet seat)
・ Provide assistance while checking for the appearance of palpitations, discomfort, nausea, dizziness, floating sensation, headache, etc.
• Help with patterns of urinary incontinence.
· Intervene while observing so as not to limit the amount of water intake due to reluctance to urinary incontinence.
・Manage the stoma. exchange, cleaning, disposal of contents, etc.
・If you have a skin problem, take a photo and save it in your medical record. Follow up and observe.
・If you have skin problems, use a protective agent.
・If you have fecal incontinence, observe the properties of your stool, and report any abnormalities such as watery or muddy indigestion to your doctor.
Use an analgesic if defecation self-care is lacking due to pain. Administer 30 minutes before exertion.
・Perform joint range of motion exercises to maintain ADL.
・Provide an environment to support what you can do on your own at home. Futon → bed life etc. Consult with a social worker or care manager to make adjustments so that you can receive the services you need.
・Listen to the anxieties of the individual and their families.
・Be careful about what you say when you are feeling down. How’s your health? Make a voice that cares about the other person. You can rest assured that you will be taken care of. Don’t try to force yourself to take him along, he seems to be in good shape, shall we go? We will help you according to your condition at that time.

3) Education plan 《EP》

・Instruct the patient not to discontinue taking the medicine on his/her own, but to take the medicine prescribed.
・Explain oral medicines and patch medicines such as analgesics. Dosage intervals, upper limit of use, etc.
・Instruct the patient to call the nurse without hesitation when providing assistance. Explain not to force yourself to move.
・Explain how to manage the stoma.
・Have a social worker explain about stoma assistance.
・If you have subjective symptoms during exertion (pain, palpitation, shortness of breath, breathing difficulty, etc.), please let us know.
・Explain that pain should not be tolerated and should be reported. Explain that analgesics can be used if needed.
・Explain how to use self-help tools.
・Explain the necessity of lifestyle rehabilitation and joint range of motion training to maintain ADL and prevent bedriddenness. After discharge from the hospital, ask the patient and their family to explain from the rehabilitation staff so that they can continue on their own.
・Explain to the family not to help too much and to provide assistance to preserve the remaining functions. (what to where)
Explain to the family how to help with meals.
・Consult with a social worker or care manager so that you can receive the services you need to live at home.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yutaka Okaniwa. (2003). Disease can be seen VOL.2 Cardiology. Medic Media Co., Ltd.
Yutaka Okaniwa. (2007). Illness can be seen VOL.4 Respiratory organs. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (Date unknown). Physical Assessment Guidebook. Igaku Shoin.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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